SOAP Note Exemplar

Submit 1 Mini-SOAP note on a patient

Submit 1 Mini-SOAP note on a patient that you saw in clinic this week. Submit as a Word Document. See example template below for required format. Review the rubric for more information on how your assignment will be graded. Demographic Data • Patient initial (one initial only), age, and gender must be Health Insurance Portability […]

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Date: July 21st, 2024

A 58-year-old female, reports experiencing increased fatigue,

SOAP Note: Nursing & Medical diagnosis/es formulated with correct ICD- 10 codes. Include health maintenance diagnosis per guidelines. You MUST provide at least 3 likely differential diagnoses and list R/Os if appropriate. Include pertinent positives & negatives for the Mgt plan cost-effective, clinically correct & includes sections for medical & nursing therapeutics. Patient education should […]

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Date: July 17th, 2024

15-year-old female presents with a 2-day history of burning pain

SOAP Note Template Encounter date: ________________________ Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____ Reason for Seeking Health Care: ______________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor Past Medical History • Major/Chronic Illnesses____________________________________________________ • Trauma/Injury ___________________________________________________________ • Hospitalizations __________________________________________________________ Past Surgical History___________________________________________________________ Medications: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Family […]

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Date: January 22nd, 2024

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